Transplanting The Gift Of Life

Dr. Alan Cheung Medical director of Transplant Institute of the Pacific at Hawaii Medical Center East

Interviewed By Melissa Moniz

Where did you receive your schooling and training?

I graduated from Harvard Medical School in Boston. After that I did a general surgery residency at the University of Washington in Seattle and a transplant fellowship at the University in Minnesota. I’ve been back in Hawaii since 1992.

What is your area of specialty?

I specialize in general surgery and transplant surgery. I do kidney and pancreas transplants, and I also help out with the liver transplants.

When did you begin working at Transplant Institute of the Pacific?

I came home in 1992 and at that time Dr. Livingston Wong was in charge of the kidney transplant program. They also had a heart and bone marrow transplant here. When I came back I told them I was interested in developing a pancreas transplant program, as well as a liver transplant program. So we started the liver transplant program in 1993 with Dr. Linda Wong, Dr. Whitney Limm and myself. And in 1993 we also started the pancreas transplant program.

Which organ is in most demand?

The biggest wait list is for kidney transplants. There are about 350 patients waiting. The next would be for liver transplants, where there are 15 to 20 patients on the wait list. The pancreas transplant list has about six or seven patients. Heart transplants usually have one to two patients on the wait list at any given time.

Do you only do organ transplants surgeries here?

No, we do general surgery and transplant surgeries here. Hawaii Medical Center East is the only federally recognized program in the state of Hawaii authorized to do transplants.

The government wants to make sure that you don’t waste organs, so you have to be approved and have the appropriate training, staff and infrastructure to make it happen.

So Hawaii Medical Center East is the only recognized transplant program, and therefore we serve all the patients of Hawaii and the Pacific Basin.

So you and the other surgeons are involved in the process from start to finish (removing the organs, finding the donor and doing to the transplant surgery)?

Well, there are two types of donors, deceased donors and living donors. For kidney transplant there’s the potential living donor. But that’s only restricted to kidneys. The deceased donor is basically someone who dies due to brain injury. So let’s say there’s a deceased donor who becomes available on Maui and I’m on call. I would fly to Maui along with members of the Organ Donor Center of Hawaii, who help us coordinate donations. I would then procure the organs and if we’re able to use those organs here in Hawaii then I would bring those organs back to HMC East. We would have a team of coordinators looking at the various patients on the wait list and calling to see if they can come in. We then do a cross-match to make sure they won’t react to the organs. Once that’s all set, then we basically start our surgery. The activity can become quite hectic because we could be doing multiple surgeries at once. It’s a fairly complex organization.

With each organ, how much time do you have from when it’s removed until it’s transplanted?

The heart has a preservation time of about six hours. So that’s why most of the hearts we procure here in Hawaii stay in Hawaii. The liver and pancreas can be preserved for about 12 to 24 hours. And the kidney can survive up to about 48 hours. So if we’re not able to use these organs locally, we can share them with programs on the Mainland. And visa versa.

Can you also talk about how someone qualifies to be an organ donor?

There are two types of deceased donors. There is the traditional brain-dead donor and the newer type of donors after cardiac death. Traditionally what we’ve used is someone who has severe, irreversible brain injury and is declared by two independent physicians to be brain dead. The Organ Donor Center of Hawaii will then approach the family and if the family wishes to donate then we’re notified.

That’s the classic type.

But because there’s such a long waiting list for organs, we’ve looked at other sources of donors. What has been added are patients who have severe, irreversible brain injury but aren’t brain dead. Many times the family wishes to withdraw life support because their loved one has previously stated that he or she doesn’t want to live in such condition. And some of those families wish to donate organs also. These patients are classified as cardiac death donors and we’ve been able to successfully transplant their kidney and liver.

What do you think is the future of organ transplants, perhaps 20 years from now?

I’d like to think we’ll continue to have improved medications that not only can decrease rejection but also minimize side effects. The biggest hurdle is simply the lack of organs. In Hawaii there are about 400 patients waiting for various organs and we only have about 30 donors a year locally. Hopefully we can find ways to expand the availability of organs, maybe with research using animals such as specialized pigs where we can harvest the heart and use that for transplantation, but that’s in the very distant future. And the other thing is stem cells and using that technology to grow islet cells or grow various organs. So you can use a person’s own cells to grow these organs, but again that’s very far away and very controversial.

Is that in the testing stages?

People have been working on that for years. If a scientist is able to figure that out, he’ll win a Nobel Prize. But it’s such a difficult problem. I don’t think it’s impossible, but I don’t think that will happen during my career. But I would certainly love to be surprised.

What’s the biggest challenge with harvesting organs from animals?

With animal organs there are two issues. One is that we seem to have natural antibodies that fight against these foreign animal tissues, so rejection is very high. The second is that animals get certain diseases and the fear is that if you do these animal transplants then those unique diseases could be transmitted to humans.